The concept of sustainability in the sense of a balance between resource consumption and reproduction was applied to forestry already in the 12th to 16th century. In the last two centuries it translated to sustainable development, to emphasize the importance of sustained human development of all the people on the globe, not just for the preservation of human existence, but especially for the assurance of a quality life for all that inhabit this earth. Currently, for good reason, sustainable development is being taken seriously by some world leaders and civil society alike.
Human development is important, not just for the obvious practical reason of improving a country’s economy, but on a more important individual level, for mental health that lends itself to gainful occupation and fulfilment. The definition of Primary Health Care (PHC) in the Alma-Ata Declaration – essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination (1) – reminds us that PHC when fully implemented, hugely contributes to human development in that it is ultimately geared towards self-reliance and self-determination.
Figure 1 below is an adaptation from the Cycle of Development contained in South Africa’s National Development Plan (NDP) (2) and depicts the importance of healthy citizens for development. An individual, a family and ultimately a community’s sociopolitical, environmental and economic conditions determine the opportunities available to them, which will lead to development of capabilities, leading to employment, personal and societal growth, poverty reduction and improved living standards. However, good health, in its comprehensive sense, is a prerequisite for the individual, the family and the community to even begin to take advantage of available opportunities.
Figure 1. Cycle of development
Health in All Policies (HiAP) is an approach to public policies across all sectors that systematically takes into account and steers clear of negative consequences for health and health systems (3). It is in the areas of “conditions” and “opportunities” that a HiAP approach should make an impact. A successful HiAP approach should make a positive difference with regard to those elements that determine an individual, a family and a community’s conditions and opportunities. In Figure 2 those elements are depicted as: 1) Love and belonging (the socio-emotional conditions a baby is born into); 2) Food security; 3) Housing; 4) Water and sanitation; 5) Education; 6) Employment; 7) Environment; 8) Social and community networks; 9) Individual lifestyle factors; 10) Sport and recreation; 11) Safety and security; 12) Peace, social justice and equity; 13) Self Esteem and self actualization.
Figure 2. Elements that determine an individual, a family and a community’s conditions and opportunities
HiAP speaks to policies across all sectors and while the health sector has a substantial role in making HiAP a reality, an ever present HiAP approach should not be the exclusive role of the health sector. The left hand column of Figure 3 indicates all the sectors in which a HiAP approach should become second nature. We need academic and research institutions to provide the evidence required to convince these sectors of the developmental benefits of this approach and we need civil society organizations and ordinary citizens to actively safeguard a HiAP approach in all these sectors. The right hand column indicates that in the Department of Health (DoH) we are already applying HiAP, and will continue to move outside our own domain to work with other sectors to achieve better health for all our citizens. We do not limit ourselves to just HiAP but also implement Health in All Actions (HiAA).
Figure 3. Implementation of HiAP approach
South Africa is more than ready and in many instances has already started to implement a HiAP approach, not just to policy development but also to policy implementation. Our citizens’ right to health care is contained in our constitution. The chapter on health in our NDP starts with the recognition that the health of our citizens is not merely a medical issue, but that the social determinants of health need to be adequately addressed if we are to realize our vision for health and thus for development.
We have active and effective inter-ministerial committees on certain social determinants of health, and Operation Sukuma Sakhe (Lets build together) and Phila Mntwana (keep babies healthy) in KwaZulu-Natal are examples of HiAA. The National DoH (NDoH) of South Africa already has a strong relationship with the departments of Agriculture, Social Development, Basic Education, Rural Development and Trade and Industry when it comes to food security, the quality of food and food safety.
We do however still have much work to do in this regard. We are yet to confirm our formal framework for addressing the SDoH and, for example, while we promote exercise as an important component of a healthy lifestyle, we have a long way to go to increase safe open public spaces for walking, running and cycling.
In conclusion, the health of populations, and how equitably health is distributed, provides a yardstick to judge progress across all aspects of economic, social and environmental policy. The health sector must act as a catalyst for HiAP, in other sectors a HiAP approach must become second nature, we need keen and relevant academic and research activity, we need active citizenry and vibrant and relevant civil society organizations to make HIAP and HiAA a reality for better health for all citizens.
Note that the views expressed in this article are those of the author(s) and do not necessarily represent the views of PHASA.
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